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LIQUID WASTE PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE..3P0 FLOOR,STOCKTON,CA 95202 (209)468-3420 2,4 FIR <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> `1„5 7-2.3 S. �3�tS4�� 12.oxo, IZ i CR . 9 s 3 5 4p f-t 3 c� r'*.1 <br /> JOB ADDRESS 43 _ <br /> fv^ PARCEL.SIZE%APN <br /> OWNER NAMET'YC�Y'��G9 <br /> ADDRESS C-"g00 <br /> 2.3Zo3 $ l�►1aST�►1 �a <br /> CITYIZIP �T11�L11��Y1•� PHON a•� + q X29 9�+ p <br /> CONTRACTOR `�+�lo'�+y � CA)yTYQ'L-1 qhs LO hlS�ADDRESS ,pp0. K�Jyri -�wQra`�Avy �v <br /> CITY/'ZIP 1•s�D 75357 PHONkl0R) S? T_ 7�1 <br /> GEOGRAPHICALINF,ORMATION:COORDIANTES: X Y TOWNSHIP_RANGE_SECTION <br /> PERC TEST(S)LID(I HOW MANY APPLICATION#! ''"-oo - (� <br /> TYPEOFSEPTICWORK: 11 NEW NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑RESIDENCE ❑COMMERICIAL ❑OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS:_ NUMBER OF EMPLOYEES:- <br /> CHARACTER <br /> MPLOYEES:_CHARACTER OF SOIL TO A DEPTH OF 3 FEET: PIT/SUMP SOIL CHARACTER: WATER TABLE DEPTH <br /> ❑SEPTICTANK/GREASETRAP TYPEIMFG CAPACITY NUMBER OF COMPARTMENTS <br /> ❑PKG TREATMENT PLANT DISTANCE TO NEAREST: WELT FOUNDATION PROPERTY LINE - <br /> ❑LIFT'STATION SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑LEACHING LINE NUMBER&LENGTH OF LINES / INFILTRATOR CHAMBERS <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑FILTER BED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST:WELL FOUNDATION: PROPERTY LINE <br /> ❑MOUNDED WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SEEPAGE PITS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> ❑SUMPS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL _FOUNDATION PROPERTY LINE <br /> ❑DISPOSAL PONDS WIDTH LENGTH DEPTH <br /> DISTANCE TO NEAREST: WELL FOUNDATION PROPERTY LINE <br /> 1 HERE Y CERTI TH T 1 NAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDIAN STA E LA S, ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> .IQ rrrt �( � ��L•'�� DATE: JJ GJ <br /> SIGNED: i*, <br /> I <br /> s f• • * •1• o Is •�• • •I* • <br /> s • ! • • • • i Djl <br /> f • • PAXEL 2 • • • • • • PARCEL I 1 <br /> . • • e�• f • • o • • ems • � � <br /> . i • • • • �� �� • • DOpDODDD � ! � -� <br /> . . • • • • • • f • • • • DDQ�DDDD <br /> • • segs • � e�e .• • • • � <br /> Aw <br /> SWAWW <br /> ao <br /> .b.s <br /> } a& <br /> 1... <br /> ��S .. .` - • �'`��iORDEPARTAtE�(T ONLY <br /> APPLICATION ACCEPTED BY: (�-�- ( -l - DATE G <br /> TANK,PR.OR SUMP INSPECTED BY: DATE' <br /> FINAL INSPECTION BY: <br /> COMMENTS: <br /> PE CODE SC AMOUNT BECK RECEIVEDBY DATE PERMIT/SERVICE REQUEST M SEPTIC IDt <br /> RFM]IT1ED <br /> J O a <br />